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Extramammary Paget’s disease (EMPD) is a rare, locally aggressive cutaneous adenocarcinoma which typically involves the anogenital region. The prognosis heavily depends on early diagnosis with definitive surgical treatment. To reduce local recurrence, wide radical resection with margin control and Moh’s micrographic surgery are conventionally recommended. We describe a case of a 65-year-old female with extensive perineal EMPD involving the vulva, vagina, ectocervix, urethra, and anal canal, extending to the sacral region. She required pelvic exenteration and skin resection with 5-cm margins. A rectus abdominis myocutaneous flap (OFRAM) was designed with a fleur-de-lis skin paddle, with the vertical limb extended in an oblique fashion. We name this the OFRAM design and it allows maximal recruitment of abdominal tissue for the reconstruction of massive pelvic defects. The oblique limb obliterated the pelvic floor defect after the pelvic exenteration, while the horizontal limbs were used to resurface the perineal defect. One week later, after formal histology confirmed oncologic clearance, a gluteal keystone flap was used to resurface the remnant posterior defect. We discuss the disease pathology and reconstructive options in such cases. Level of Evidence: Level V, therapeutic study.

OBJECTIVES Cardiopulmonary bypass in cardiac surgery has been associated with several deleterious effects including haemodilution and systemic inflammation. Modified ultrafiltration (MUF) has been well established in paediatric cardiac surgery in counteracting postperfusion syndrome. However, MUF is less commonly used in adult cardiac surgery. In this meta-analysis, we compared clinical outcomes in adult patients who underwent cardiopulmonary bypass with and without MUF. METHODS Electronic searches were performed using Pubmed, Ovid Medline, EMBASE and the Cochrane Library until April 2020. Selection criteria were randomized studies of adult cardiac surgery patients comparing MUF versus no MUF. Primary outcomes were postoperative mortality, haematocrit, blood transfusion, chest tube drainage, duration of intensive care unit (ICU) stay and duration of mechanical ventilation. RESULTS Thirteen randomized controlled trials were included, comprising 626 patients in the MUF group, and 610 patients in the control (no-MUF) group. There was a significantly improved postoperative haematocrit [mean difference 2.70, 95% confidence interval (CI) 0.68–4.73, P = 0.009], lower chest tube drainage (mean difference −105 ml, 95% CI −202 to −7 ml, P = 0.032), lower postoperative blood transfusion rate (mean difference −0.73 units, 95% CI −0.98 to −0.47 units, P CONCLUSIONS MUF is a safe and feasible option in adult cardiac patients, with significant benefits including improved postoperative haematocrit, as well as reduced postoperative chest tube bleeding, transfusion requirements and duration of ICU stay.

The left atrial appendage (LAA) aneurysm is a rare condition that can produce local compressive effects and complications including supraventricular tachyarrhythmias, thromboembolic events and myocardial ischaemia. We present a rare case of a neonate with a congenital LAA aneurysm which resulted in local compressive effects on the left ventricle, severe mitral regurgitation and malposition of the left anterior descending (LAD) coronary artery. Intraoperatively, the LAD was found to be within the aneurysmal wall exterior to the left ventricular epicardium and was inadvertently injured during LAA aneurysm resection. Retrospective review of the preoperative computed tomography and echocardiography scans demonstrated the LAD lying within the wall of the LAA aneurysm, although this had not been well appreciated at that time. This highlights the importance of thorough multimodal preoperative imaging and intraoperative assessment for recognition of this rare association between the LAA aneurysm and LAD malposition, and prevention of inadvertent LAD injury during aneurysm resection.

Diabetic burns patients may be at risk of worse clinical outcomes. This study aims to further investigate the impact of diabetes mellitus on clinical outcomes in burns patients in Singapore.A 3-year retrospective review was performed at the Singapore General Hospital Burns Centre (2011-2013). Pure inhalational burns were excluded. Diabetic (N=53) and non-diabetic (N=533) patients were compared, and the impact of diabetes on clinical outcomes, adjusting for confounders, was investigated using multivariate logistic regression.The diabetic group had a significantly higher incidence of wound infection and severe renal impairment, as well as a longer length of stay, higher number of operations and higher rate of unplanned readmission. ICU admission was significantly associated with hyperglycaemia (OR 5.44 [2.61-11.35], p0.001) and a higher total body surface area of burn (OR per 1% TBSA 1.07 [1.05-1.09], p0.001). Unplanned readmission was significantly associated with wound infection (OR 4.29 [1.70-10.83], p=0.002), and mortality associated with a higher TBSA (OR per 1% TBSA 1.1 [1.07-1.14], p0.001). After adjusting for confounders, diabetes mellitus was not significantly associated with unplanned readmission or mortality.Diabetic burns patients have an increased risk of worse clinical outcomes, including wound infections, renal impairment and longer length of stay.